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APPL,�;ATION FOR SANITATION PERMI Permit No. �. (Complete in Duplicate) 1a Date lssuecl ----- Application is hereby made to the San Joaquin Local Health District for a p it to const nd install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION.. �-rz,I -....-+rr_. G�:_: • = —I f'hG 1 •�''!,Fjp ` Owner's Name----------f__z_IL ' =__ _� �-� � _____ _ _rly_______ Phone j Ph #� Address f1` �O S. tJrI ,Bz - s - -------------- ' ` =--- ---- ---- ----------------- -----------Contractor's-Name_-_=______________ - --------------------=•------•-- ---=-------------------------- ------------ ----------- - - ------------------------- Phone Installation will serve: Residence V Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑' �, Number of living units:l_ �Nuof bedrooms ___�___ Number of baths _ -__ Loti size i Water Supply: Public system-[-] Community system kr Private ❑ Depth to Water Table _. ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 0 Clay ❑ AdobeX-- Hardpan C] Previous Application Made: Yes` No ❑ New Construction: Yes W. NojEj 1 FHA%VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND rSPEC IFICATIONS: } {No septic tank or'cesspool permitted if public sewer is available within 200-feet.) , •z Septic Tank: Distance from nearest well__5D---------Distance from foundation_____VO__-I.-----.Material____ t t`'?'�- -'----- No, of compartments------2---------------Size_J2_X_9_X_!5..�c....Liquid depth � -------_ --Capacity_- 1I1a p Field: Distance from nearest well '��____Distance from foundation _ __ '_----- Distance to nearest lot lin e-_. Number of lines_____ ___ _ (� ---- -- ----------- -Length of each line-! .--'--- �----� Width of trench ---.��.---- ------------ ------ i s❑sa Type of filter mateiial__-RO_CA-_----Depth of filter material___.--��_�________-_Total length_____________3pEa____.___ Seepage ----------------------Pit: Distance from foundation_-_.---- to nearest lot line---------------- El _____.__.___,❑ Number of pits.-----`--------------Lining material-----------------------size D_iarneter------------------------Depth---------------------------_----- Cesspool: Distance from nearest well-----------------Distance from foundation__-- ---#-.___.Lining L. + ' ' - material--- _----------------- ----____. ❑ lDmr _ ----------- - Liquid Capacity-------------------------- g_>a�l_s_ . Privy' w,r� : Dis#ance romnearest well---_- _ -- ---D : - �'Distanee from nearest builing___-----______________________________ ❑ -----_-___- �L Distanceto nearestlot line-- -- --------------------------------------------- ----------------------•-------------------------------------------------------- Remodeling � , and/or repairing.(describe)---------------------------------- ------------------------------------------------•-----------------•---------••-------------- -==`--- -- -- ._�. -------------------------------------------- r r - - ' It I # # ordinances, ------ -------------------------------------------------------------------------- ----------- - -- - I hereby certify that I have prepared this application and that the work willibe done in accordance with San Joaquin County es, State laws,-and rulesandregulations of the San Joaquin Local Health District. (Signed')- _!LAG ,�- - -- -- -------- ---- --- ----------- r----------------------(Owner and/or Contractor) Y� _ :, �{ '- �: ;, 9 *��- 1;-Y=(TitleP j ------------ v (Plot plan, showing size of lot, location of system in relation to;wells buildin s, etc.,•can be laced on reverse side). _ �i + A Y i >! FOR DEPARTMENT USE ONLY { REVIEWED TION ACCEPTED BY- tom = = - �/ -�`"�� APPLICATION j� i f --- ----------•--------- - - DATE -- ---- - -- ------------------ -- -i------ DATE ------ ----------------------- AI+I�D1NG PERMIT ISSUED -` 1_ `--...f ---F DATE or recommendations:_ 1-Q -._ _ _ --- _� ---- ; ' x�' . —- "- ..------- - -''+1 rte_ _ r • �-,r••X-7-'------�-•----- a ---------- . ------•------ ----------------•---------•--------•-----------=------------------------------------------------------- ^- ------ r -------------------------------------------------------------------•-------- -------- FINAL INSPECTION BY: 1- . /SAYNJOjUIN ----------- Date-- �{ - 1 LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton,. California Lodi, California Manteca, California Tracy, California ES-4-21x1 Revised 1.57 1=.P.CQ. S�